Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 9512 | MT |
NPI | 1457573727 |
---|---|
Provider Name | Dr. Brian Robert Chisdak |
First Address | Bozeman, MT 59715 |
Second Address | Bozeman, MT 59715 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 08/07/2007 |